Mental illness and help-seeking behaviours among Middle Eastern cultures: A systematic review and meta-synthesis of qualitative data

Background Western literature has long explored help-seeking behaviours related to mental health issues. However, this has been relatively neglected in the Middle East despite an increase in mental health needs in the region. The purpose of this review was to conduct a systematic review and qualitative meta-synthesis exploring help-seeking behaviours related to mental health issues in the Middle East. Methods We conducted a systematic review and meta-synthesis to gain a comprehensive overview of what is known about mental health and help-seeking behaviours in the Middle East from published qualitative research in the Middle Eastern region. A search of electronic databases (MEDLINE, Embase, CINAHL, PsycINFO and QScience) was carried out from inception to July 2022. The quality of the included studies was assessed using the Critical Appraisal Skills Programme tool, and the review protocol was pre-registered with PROSPERO (Ref: CRD42022311494). Results We identified 16 qualitative studies exploring mental health-seeking behaviours in Middle East countries. Facilitators and barriers to help-seeking were captured under six overarching themes. Across all studies, we identified negative attitudes towards seeking help for mental health issues, economic and structural barriers to accessing mental healthcare, and misconceptions surrounding religious beliefs, all of which had a critical role in impacting decisions to seek mental healthcare services. Many sought help from alternative sources, such as traditional healers or family members before consulting a healthcare professional. The role of the family and cultural norms was also identified as key contributors to people’s help-seeking behaviours. Conclusions This meta-synthesis indicates the existence of many challenges surrounding mental health-seeking in the Middle East, including public and internalizing stigmas. This suggests an urgent need for an increase in psychoeducation and mental health awareness in the region.


Information sources
6 Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted to identify studies.Specify the date when each source was last searched or consulted.

P9
Search strategy 7 Present the full search strategies for all databases, registers and websites, including any filters and limits used.P9, 50 Selection process 8 Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.

Data collection process
9 Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.

P11
Data items 10a List and define all outcomes for which data were sought.Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect.

P11
10b List and define all other variables for which data were sought (e.g.participant and intervention characteristics, funding sources).Describe any assumptions made about any missing or unclear information.

P9 Study risk of bias assessment
11 Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.

P13
Effect measures 12 Specify for each outcome the effect measure(s) (e.g.risk ratio, mean difference) used in the synthesis or presentation of results.N/A Synthesis methods 13a Describe the processes used to decide which studies were eligible for each synthesis (e.g.tabulating the study intervention characteristics and comparing against the planned groups for each synthesis.

P11-12
13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.

N/A
13c Describe any methods used to tabulate or visually display results of individual studies and syntheses.P11 13d Describe any methods used to synthesize results and provide a rationale for the choice(s).If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.

P8, P11-12
13e Describe any methods used to explore possible causes of heterogeneity among study results (e.g.subgroup analysis, meta-regression).N/A

# Checklist item
Location where item is reported 13f Describe any sensitivity analyses conducted to assess robustness of the synthesized results. N/A

Reporting bias assessment
14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).P13, P20 Certainty assessment 15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.P20

Study selection 16a
Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.

P14-15
16b Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.P14

Study characteristics
17 Cite each included study and present its characteristics.

P16-19
Risk of bias in studies 18 Present assessments of risk of bias for each included study.

Results of individual studies
19 For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g.confidence/credible interval), ideally using structured tables or plots.

N/A
Results of syntheses 20a For each synthesis, briefly summarise the characteristics and risk of bias among contributing studies.P16 20b Present results of all statistical syntheses conducted.If meta-analysis was done, present for each the summary estimate and its precision (e.g.confidence/credible interval) and measures of statistical heterogeneity.If comparing groups, describe the direction of the effect.
of all investigations of possible causes of heterogeneity among study results.N/A 20d Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.N/A Reporting biases 21 Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.P20 Certainty of evidence 22 Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.P11, 13-14 DISCUSSION Discussion 23a Provide a general interpretation of the results in the context of other evidence.P35-38 23b Discuss any limitations of the evidence included in the review.P39 23c Discuss any limitations of the review processes used.P38-39 23d Discuss implications of the results for practice, policy, and future research.P39-40